Quality of end-of-life care in the emergency department

Abstract

ObjectiveTo assess appropriateness of end-of-life treatments provided to actively dying patients attending the emergency department of a primary care hospital.MethodsRetrospective cohort study of patients who died in the emergency department of a French primary care hospital between January 2014 and January 2017. The deceased were identified through the admissions register. Then, electronic medical records were screened for bio-demographic data, data relative to decisions to withhold or withdraw treatments, to diagnosis and to the care provided. Patients were clustered into two categories, actively dying or non-actively dying, using clinical opinion based on their medical records. Appropriateness of care was appraised following French guidelines.ResultsOne hundred and forty-six deaths were recorded. Actively dying patients mostly suffered from vascular conditions (29.4%). When compared to the overall sample, they were more likely to have decisions to withhold or withdraw treatments (OR = 5.3 [1.56; 20.7], p-value = 0.003), to have strong opioids (OR = 5.32 [2.1; 13.9], p-value <0.0001), hypnotics (OR = 2.6 [0.95; 8.39], p-value = 0.05), and scopolamine (OR = 2.5 [1.1; 6.13], p-value = 0.03). Moreover, they were less likely to have unbeneficial treatments in terminal conditions, such as resuscitation care (OR = 0.06 [0.001; 0.52], p = 0.002) and antibiotics (OR = 0.42 [0.19; 0.92], p-value = 0.022). There were no differences in rate of hydration, venous access and use of tracheal aspirations.ConclusionsOverall, actively dying patients were appropriately supported. However, several issues regarding hydration management, drug administration routes, and broncho-pulmonary secretions management remain to be addressed.

Práticas de cuidado hospitalares no final de vida: revisão integrativa

“…Em relação à caracterização dos estudos, quanto ao desenho metodológico, 38 eram de abordagem quantitativa (Årestedt et al, 2018;Axelsson et al, 2018;Beauverd et al, 2014;Bedell et al, 1986;Camhi et al, 2009;Chang & Brass, 2014;H.-C. Chou et al, 2018;Clarke et al, 2014;Cook et al, 1995;Courtwright et al, 2015;DeMartino et al, 2017;Economos et al, 2019;Farrington et al, 2014;Fu et al, 2018;Gilbar et al, 2019;Hamano et al, 2018;Hiramoto et al, 2019;Koff et al, 2017;Liu et al, 2015;Moffat et al, 2016;Montagnini et al, 2018;Mori et al, 2019;Mroueh et al, 2019;Opstelten et al, 2017;Parpa et al, 2010;Penders et al, 2020;Penrod et al, 2012;Piili et al, 2018;Pugh et al, 2009;Seale, 2010;Steindal et al, 2015;Syed et al, 2017;Taniguchi et al, 2016;Thomas et al, 2014;Tsai et al, 2018;Verhofstede et al, 2017;Wang et al, 2019;Ziegler et al, 2018), 13 qualitativa (Bélanger et al, 2014;W.-Y. S. Chou et al, 2017;De Bal et al, 2006;De W...…”

“…S. Chou et al, 2017;De Bal et al, 2006;De Witt Jansen et al, 2017;DeMartino et al, 2017;Guardia-Mancilla et al, 2017;Koff et al, 2017;Kruser et al, 2017;Opstelten et al, 2017;L. Robijn et al, 2017;Sellars et al, 2017;Syed et al, 2017;Verhofstede et al, 2017;Wagemans et al, 2017), 2018 (Årestedt et al, 2018;Axelsson et al, 2018;H.-C. Chou et al, 2018;Fu et al, 2018;Hamano et al, 2018;Montagnini et al, 2018;Piili et al, 2018;Lenzo Robijn et al, 2018;Scott et al, 2018;Tsai et al, 2018;Ziegler et al, 2018(Díez-Manglano et al, 2019Economos et al, 2019;Gilbar et al, 2019;Hiramoto et al, 2019;Mori et al, 2019;Mroueh et al, 2019;Wang et al, 2019), respectivamente.…”

“…S. Chou et al, 2017;Clarke et al, 2014;Cook et al, 1995Cook et al, , 1995De Bal et al, 2006;De Witt Jansen et al, 2017;DeMartino et al, 2017;Díez-Manglano et al, 2019;Farrington et al, 2014;Gilbar et al, 2019;Guardia-Mancilla et al, 2017;Hamano et al, 2018;Hiramoto et al, 2019;Kruser et al, 2017;Kryworuchko et al, 2016;Le & Watt, 2010;Liu et al, 2015;McIlvennan et al, 2017;Montagnini et al, 2018;Mori et al, 2019;Parpa et al, 2010;Penders et al, 2020;Philip et al, 2019;Piili et al, 2018;Pugh et al, 2009;Reid et al, 2015;L. Robijn et al, 2017;Lenzo Robijn et al, 2018;Robinson et al, 2007;Scott et al, 2018;Seale, 2010;Sellars et al, 2017;Steindal et al, 2015;Syed et al, 2017;Taniguchi et al, 2016;Thomas et al, 2014;Verhofstede et al, 2017;Wagemans et al, 2017;Ziegler et al, 2018), seguido pelo nível IV, identificado em 10 estudos (Camhi et al, 2009;H.-C. Chou et al, 2018;Economos et al, 2019;Fu et al, 2018;…”

“…Os artigos com maior nível de evidência foram classificados como N2 (Moffat et al, 2016) e como N4 (Camhi et al, 2009; H.-C. Chou et al, 2018Chou et al, , 2018Economos et al, 2019;Fu et al, 2018;Koff et al, 2017;Mroueh et al, 2019;Opstelten et al, 2017;Penrod et al, 2012;Tsai et al, 2018). A partir da conclusão de tais estudos recomenda-se que pacientes hospitalizados com ordem de não reanimação recebam maior atenção da equipe de enfermagem, por meio de cuidados centrados no conforto (Moffat et al, 2016).…”

“…Na fase agônica de doenças em estágio avançado, ou seja, as últimas 72 ou 48 horas de vida, é considerado inapropriado o uso de cateter venoso periférico ou central, hidratação com mais de 500ml por cristaloides, antibióticos, reanimação cardiopulmonar, nutrição artificial e aspiração traqueal. Em termos farmacológicos, nesta fase, indica-se a prescrição de analgésicos, escopolamina, hipnóticos e ansiolíticos (Economos et al, 2019). Vasopressores não são indicados, exceto em situações que o médico considere que a droga tem efeito benéfico ao paciente (H.-C. Chou et al, 2018).…”